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00:00.0 Dr. Martens is director of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience and advisor of the Forensic Psychiatry Hospital in Assen, The Netherlands. Psychopathy is characterized by diagnostic features such as superficial charm, high intelligence, poor judgment and failure to learn from experience, pathological egocentricity and incapacity for love, lack of remorse or shame, impulsivity, grandiose sense of self-worth, manipulative behavior, poor self-control, pathological lying, promiscuous sexual behavior, juvenile delinquency, and criminal versatility among others (Cleckley, 1982; Hare et al., 1990). As a consequence of these criteria the psychopath has the image of a cold, heartless, inhuman being. But do all psychopaths show a complete lack of normal emotional capacities and empathy? Like healthy people, many psychopaths love their parents, spouse, children and pets in their own way, but have difficulty loving and trusting the rest of the world. Furthermore, psychopaths do suffer emotionally as a consequence of separation, divorce, death of a beloved person or dissatisfaction with their own deviant behavior (Martens, 1997). Sources of Sadness Psychopaths can suffer emotional pain for a variety of reasons. Like anyone else, psychopaths have a deep wish to be loved and cared for. This desire remains frequently unfulfilled, however, as it is obviously not easy for another person to get close to someone with such repellent personality characteristics. Psychopaths are at least periodically aware of the effects of their behavior on others and can be genuinely saddened by their inability to control it. The lives of most psychopaths are devoid of a stable social network or warm, close bonds. The life histories of psychopaths are often characterized by a chaotic family life, lack of parental attention and guidance, parental substance abuse and antisocial behavior, poor relationships, divorce, and adverse neighborhoods (Martens, 2000). They may feel that they are prisoners of their own etiological determination and believe that they had, in comparison with normal people, fewer opportunities or advantages in life.
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Psychiatric Times. Vol. 19 No. 1
The Hidden Suffering of the Psychopath
By Willem H.J. Martens, M.D., Ph.D. | 2001-12-31 19:00:00.0
Dr. Martens is director of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience and advisor
of the Forensic Psychiatry Hospital in Assen, The Netherlands.
Psychopathy is characterized by diagnostic features such as superficial
charm, high intelligence, poor judgment and failure to learn from
experience, pathological egocentricity and incapacity for love, lack of
remorse or shame, impulsivity, grandiose sense of self-worth,
manipulative behavior, poor self-control,pathological lying,
promiscuous sexual behavior, juvenile delinquency, and criminal
versatility among others (Cleckley, 1982; Hare et al., 1990). As a
consequence of these criteria the psychopath has the image of a cold,
heartless, inhuman being. But do all psychopaths show a complete lack
of normal emotional capacities and empathy? Like healthy people, many
psychopaths love their parents, spouse, children and pets in their own
way, but have difficulty loving and trusting the rest of the world.
Furthermore, psychopaths do suffer emotionally as a consequence of
separation, divorce, death of a beloved person or dissatisfaction with
their own deviant behavior (Martens, 1997).
Sources of Sadness
Psychopaths can suffer emotional pain for a variety of reasons. Like anyone else, psychopaths have a
deep wish to be loved and cared for. This desire remains frequently unfulfilled, however, as it is
obviously not easy for another person to get close to someone with such repellent personality
characteristics. Psychopaths are at least periodically aware of the effects of their behavior on others and
can be genuinely saddened by their inability to control it. The lives of most psychopaths are devoid of a
stable social network or warm, close bonds.
The life histories of psychopaths are often characterized by a chaotic family life, lack of parental
attention and guidance, parental substance abuse and antisocial behavior, poor relationships, divorce,
and adverse neighborhoods (Martens, 2000). They may feel that they are prisoners of their own
etiological determination and believe that they had, in comparison with normal people, fewer
opportunities or advantages in life.
Despite their outward arrogance, inside psychopaths feel inferior to others and know they are
stigmatized by their own behavior. Although some psychopaths are superficially adapted to their
environment and are even popular, they feel they must carefully hide their true nature because it will not
Psychiatric Times. Vol. 19 No. 1 December 31, 2001
http://www.psychiatrictimes.com/display/article/10168/55051 1
be accepted by others. This leaves psychopaths with a difficult choice: adapt and participate in an
empty, unreal life, or do not adapt and live a lonely life isolated from the social community. They see
the love and friendship others share and feel dejected knowing they will never take part in it.
Psychopaths are known for needing excessive stimulation, but most foolhardy adventures only end in
disillusionment due to conflicts with others and unrealistic expectations. Furthermore, many
psychopaths are disheartened by their inability to control their and are repeatedlysensation-seeking
confronted with their weaknesses. Although they may attempt to change, low fear response and
associated inability to learn from experiences lead to repeated negative, frustrating and depressing
confrontations, including trouble with the justice system.
As psychopaths age they are not able to continue their energy-consuming lifestyle and become
burned-out and depressed, while they look back on their restless life full of interpersonal
discontentment. Their health deteriorates as the effects of their recklessness accumulate.
Emotional Pain and Violence
Social isolation, loneliness and associated emotional pain in psychopaths may precede violent criminal
acts (Martens, 2000, 1999, 1997; Palermo and Martens, in press). They believe that the whole world is
against them, eventually becoming convinced that they deserve special privileges or rights to satisfy
their desires. As psychopathic serial killers and expressed, violentJeffrey Dahmer Dennis Nilson
psychopaths ultimately reach a point of no return, where they feel they have cut through the last thin
connection with the normal world. Subsequently their sadness and suffering increase, and their crimes
become more and more bizarre (Palermo and Martens, in press).
Dahmer and Nilsen have stated that they killed simply for company (Palermo and Martens, in press).
Both men had no friends and their only social contacts were occasional encounters in homosexual bars.
Nilsen watched television and talked for hours with the dead bodies of his victims; Dahmer consumed
parts of his victims' bodies in order to become one with them: he believed that in this way his victims
lived further in his body.
For the rest of us it is unimaginable that these men were so lonely -- yet they describe their loneliness
and social failures as unbearably painful. They each created their own sadistic universe to avenge their
experiences of rejection, abuse, humiliation, neglect and emotional suffering.
Dahmer and Nilsen claimed that they did not enjoy the killing act itself. Dahmer tried to make zombies
of his victims by injecting acid into their brains after he had numbed them with sleeping pills. He
wanted complete control over his victims, but when that failed, he killed them. Nilsen felt much more
comfortable with dead bodies than with living people -- the dead ones could not leave him. He wrote
poems and spoke tender words to the dead bodies, using them as long as possible for company. In other
violent psychopaths, a relationship has been found between the intensity of sadness and loneliness and
the degree of violence, recklessness and impulsivity (Martens, 1999, 1997; Palermo and Martens, in
press).
Self-Destruction
Violent psychopaths are at high risk for targeting their aggression toward themselves as much as toward
others (W.H.J.M., unpublished data). A considerable number of psychopaths die a violent death a
relatively short time after discharge from forensic psychiatric treatment due to their own behavior (for
Psychiatric Times. Vol. 19 No. 1 December 31, 2001
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instance as a consequence of risky driving or involvement in dangerous situations) (Black et al., 1996;
Martens, 1997). Psychopaths may feel that all life is worthless, including their own (Martens, 1997;
Palermo and Martens, in press).
Treatment Developments
In the last decade, neurobiological explanations have become available for many of the traits of
psychopathy. For example, impulsivity, recklessness/irresponsibility, hostility and aggressiveness may
be determined by abnormal levels of neurochemicals including monoamine oxidase (MAO), serotonin
(5-HT) and 5-hydroxyindoleacetic acid (5-HIAA), triiodothyronine (T3), free-thyroxine (T4),
testosterone, cortisol, adrenocorticotropic hormone (ACTH), and hormones of the
hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes (W.H.J.M., unpublished data).
Other features like sensation-seeking and an incapacity to learn from experiences (Lykken, 1995) might
be linked to cortical underarousal (Martens, 2000, 1997; Zuckerman, 1994). Sensation-seeking could
also be related to low levels of MAO and cortisol and high concentrations of gonadal hormones, as well
as reduced prefrontal grey matter volume (Raine, 1996; Raine et al., 2000; Zuckerman, 1994). Many
psychopaths can thus be considered, at least to some degree, victims of neurobiologically determined
behavioral abnormalities that, in turn, create a fixed gulf between them and the rest of the world.
It may be possible to diminish traits like sensation-seeking, impulsivity, aggression and related
emotional pain with the help of psychotherapeutic, psychopharmacological and/or neurofeedback
treatment.
Long-term psychotherapeutic treatment (at least five years) seems effective in some categories of
psychopaths, in so far as psychopathic personality traits may diminish (Dolan, 1998; Dolan and Coid,
1993; Sanislow and McGlashan, 1998).
Psychotherapeutic treatment alone may be insufficient to improve symptoms. Psychopharmacological
treatment methods may help normalize neurobiological functions and related behavior/personality traits
(Martens, in press, 2001, 2000). is impressive in treating antisocial, aggressive and assaultiveLithium
behavior (Bloom and Kupfer, 1994; Sheard et al., 1976; Tupin et al., 1973). Hollander (1999) found that
mood stabilizers such as (Depakote), , divalproex selective serotonin reuptake inhibitors monoamine
and have documented efficacy in treating aggression andoxidase inhibitors (MAOIs) neuroleptics
affective instability in impulsive patients. To date there have been no controlled studies of the
psychopharmacological treatment of other core features of psychopathy.
Cortical underarousal and low can be substantially reduced with the helpautonomic activity-reactivity
of adaptive neurofeedback techniques (Martens, 2001; Raine, 1996).
Case Study
"Norman" was raised by his aunt, as his parents were divorced and neither were capable of or interested
in caring for him. As a child and adolescent, he had numerous encounters with law enforcement for
joyriding, theft, burglary, fraud, assault and battery. He was sent to reform school twice. When he was
21 years old, he was convicted of armed robbery and served a year and a half in jail. His only close
friend was another violent criminal; he had many short-term relationships with girlfriends. At 29, he
killed two strangers in a bar who had insulted him and was sentenced to forensic psychiatric treatment.
Norman was diagnosed as a psychopath, according to (Hare et al., 1990).Hare's Psychopathy Checklist
Norman showed little improvement over the course of seven years of behavioral psychotherapy and
became less and less motivated. The staff of the forensic psychiatric hospital considered him untreatable
Psychiatric Times. Vol. 19 No. 1 December 31, 2001
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and intended to stop all treatment attempts. Norman's lawyer arranged for an examination by a forensic
neurologist, who subsequently found that Norman suffered from severe cortical underarousal, 5-HT and
MAO abnormalities, and concentration problems.
Norman was started on d,l-fenfluramine (Pondimin), a serotonin-releasing drug. (Fenfluramine was
) Acute challenge doses (0.2 mg/kg to 0.4voluntarily withdrawn from the U.S. market in 1997 -- Ed.
mg/kg) produced significant dose-dependent decreases in impulsive and aggressive responses. After one
month, an MAOI (pargyline [Eutonyl], 10 mg/kg) and psychodynamic psychotherapy were added.
Pargyline produced some normalization of his electroencephalogram (EEG) pattern and was titrated up
to 20 mg/kg over five months. Neurofeedback was started after two months and continued for 15
months. His EEG pattern gradually normalized, and his capacities for concentration and attention
increased.
Norman continued to receive d,l-fenfluramine and psychotherapy for two years, at which point he was
discharged from forensic treatment. He voluntarily continued psychotherapy for an additional three
years and, in the four years since his release, has not reoffended.
Conclusions
It is extremely important to recognize hidden suffering, loneliness and lack of self-esteem as risk factors
for violent, criminal behavior in psychopaths. Studying the statements of violent criminal psychopaths
sheds light on their striking and specific vulnerability and emotional pain. More experimental
psychopharmacological, neurofeedback and combined psychotherapeutic research is needed to prevent
and treat psychopathic behavior.
The current picture of the psychopath, which is reflected in the leading diagnostic criteria of
psychopathy offered by Cleckley (1982) and Hare et al. (1990), is incomplete because emotional
suffering and loneliness are ignored. When these aspects are considered, our conception of the
psychopath goes beyond the heartless and becomes more human.
COMMON MEDICATIONS
Lithium
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Chapter
Psychopathy, also known diagnostically as sociopathy and antisocial or dyssocial personality disorder, can be described as a chronic constellation of callous, immoral, manipulative, aggressive, or violent personality traits and behaviors. While antisocial tendencies have historically been extensively studied through various lenses, exceedingly little has been written regarding psychopathy from the perspective of existential psychology and psychotherapy (see Diamond SA, Anger, madness, and the daimonic: the psychological genesis of violence, evil, and creativity. Foreword by Rollo May. State University of New York Press, 1996; Diamond SA, J Appl Psychoanal Stud 5:21–45, 2003; Diamond SA, Violence as secular evil: forensic evaluation and treatment of violent offenders from the viewpoint of existential depth psychology. In: Mason T (ed) Forensic psychiatry: influences of evil, Humana Press, pp 179–206, 2006). Thus, this chapter explores the phenomenon of psychopathy from the frame of reference of contemporary existential therapy and seeks to shed light on how the existentially inclined forensic clinician evaluates, conceptualizes, and conducts treatment with psychopathic or antisocial patients. It provides brief definitions and descriptions of both psychopathy and existential therapy, examines the existential roots of the frustration, anger, rage, resentment, hostility, and hatred that can lead to psychopathic cruelty, malevolence, depravity, and destructiveness, and considers how the existential approach to psychopathy differs fundamentally from most mainstream therapies today. Further, this exploration delves deeply into psychopathy not only from the standpoint of existential psychotherapies in general (see, for example, Cooper M, Existential therapies, 2nd edn. SAGE. (Original work published 2003), 2016), but from that of a specific form of existential therapy the author refers to as “existential depth psychology” (Diamond SA, Anger, madness, and the daimonic: the psychological genesis of violence, evil, and creativity. Foreword by Rollo May. State University of New York Press, 1996). Drawing and building upon the existential psychoanalysis of Rollo May and the author’s own more than four decades of professional experience as a clinical and forensic psychologist and practicing psychotherapist (see Diamond SA, Anger, madness, and the daimonic: the psychological genesis of violence, evil, and creativity. Foreword by Rollo May. State University of New York Press, 1996; Diamond SA, Existential Analysis, 10, 27–41, 1999; Diamond SA, J Appl Psychoanal Stud 5:21–45, 2003; Diamond SA, Violence as secular evil: forensic evaluation and treatment of violent offenders from the viewpoint of existential depth psychology. In: Mason T (ed) Forensic psychiatry: influences of evil, Humana Press, pp 179–206, 2006; Existential therapy: confronting life’s ultimate concerns. In Tinsley H, Lease S, Giffin Wiersma N (eds) Contemporary theory and practice in counseling and psychotherapy. SAGE, pp 323–352, 2016; Diamond SA, J Humanist Psychol, 2018), existential depth psychology synthesizes, integrates and reconciles the “depth psychology” of Freud, Adler, Rank, and particularly, Carl Jung’s analytical psychology, with existential analysis or existential therapy (Diamond SA, J Humanist Psychol, 2018, online).KeywordsExistential therapyPsychopathyAntisocial personality disorderSociopathyDyssocial personality disorderPsychopathic narcissismNihilismGuiltAnxietyRollo MayIrvin YalomViktor FranklJ.-P. SartreC.G. JungSigmund FreudExistentialismExistential analysisExistential psychotherapyExistential depth psychologyPhenomenologyAngerRageViolenceEvilThe daimonicSerial killersMass shootings
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Psychopathy, in its literal sense, is a dangerous disorder. It exhibits antisocial behavior, inclusive of rage or aggression, fantasy, etc. The current psychopath population is 1%, but this paper puts forth the probability of an increase in the current population. No individual scores a zero on the Levenson scale, and that in itself shows the innate harsh tendencies of the individual, hidden behind the social norms and good values, however, this paper shows how those could be affected and cause the individual to rank higher on the APD scale (given below), resulting in undesired antisocial behavior or the potential behavior. In this paper, we have taken the scores of the different generations (gen x, millennials, and gen z) to outline the statistical change in the scores to predict an estimate. This paper, through the different variables and the statistics, deduces an increase in the APD population to be a likely one in the future to come through theoretical prediction. (Previously published as 'Prediction of a Rise in Antisocial Personality Disorder through Cross - Generational Analysis')
Thesis
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The concept of psychopathy is unlike most other mental disorders in the lack of observations of vulnerability and pain in those affected. Rather, the psychopath’s callous and self-centered ways are known to evoke suffering in others. Measures are developed to identify these characteristics in a reliable way. However, increased accuracy has not led to better treatment. As a consequence, this study aimed to investigate whether the current understanding of psychopathy is changing, or should be changed, and if central changes in the concept and measurement of psychopathy require a modification of the way we handle the problem today? Hallmarks of the current paradigm were challenged through 3 research questions: 1. Are psychopathy and suffering mutually exclusive constructs? 2. Is the psychopath more than the persistent callous, grandiose and ruthless characteristics that we usually see? 3. Is the psychopath deprived of a capacity to change? The first article of the thesis reviews previously published (1980-2009) cases of offenders with severely psychopathic traits (n=11). Vulnerability and pain in psychopaths were consistent with empirical evidence and concepts associated with object relations theory, Reid (1986) and Martens’ (2002) clinical experience of suffering in psychopaths, and comorbid symptom- and personality pathology, as indicated by the authors’ assessment and the selfreport of individual offenders. Articles two and three draw from an in-depth investigation of Norwegian high-security and detention prisoners with possible and strong indications of psychopathy (n=16) and controls (n=35). Results indicate important nuances in psychopathic offenders’ affective and interpersonal functioning in terms of relational uncertainties and pain, and a greater emotional range than what is previously reported. Results further indicate a link between empirical findings and clinical theory describing structural affective, relational and defensive nuances in pathologically extreme self-states, which should be considered in future treatment of psychopathy. Results are incongruent with Cleckley’s (1941; 1988) recognized description, and the wellestablished primary-secondary psychopathy distinction (Karpman, 1941), and in agreement with the dimensional model of self- and interpersonal functioning advised in APA’s (2010) proposed revision of personality diagnoses. Future work should focus on the vulnerability and suffering, nuances and adjacent treatment of psychopathy. Such an approach would represent a paradigm shift in this field.
Article
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Antisocial and psychopathic personality disorders can be linked to a number of biochemical abnormalities (e.g., serotonin, monoamine oxidase, and hormone dysfunctions), genetic and environmental influences, and psychological and social manifestations. Children with conduct disorders, with or without attention deficit hyperactivity disorder, have an elevated risk for antisocial or psychopathic personality disorders in adolescence and adulthood. The presence of comorbid disorders such as substance abuse and schizophrenia have a strong negative predictive value with respect to the course, the prognosis, and the outcome of antisocial and psychopathic disorders. Furthermore, there are substantial gender differences. The rates for spontaneous remission and improvement of antisocial and psychopathic personality disorders are possibly relatively high. In fact, these rates are higher for women than for men. In the fourth decade of life, most of the antisocial and psychopathic personalities are in remission.
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This book provides a comprehensive review of the treatment of psychopathic and antisocial personality disorders. It will be of interest to criminologists, penologists, and probation officers, as well as psychologists and psychiatrists. After an overview of contemporary diagnostic concepts of psychopathic disorder and a review of natural history studies, outcome studies of various treatment modalities are considered in a range of settings (the community, non-secure hospitals, secure units, Special Hospitals and prisons). Deficits in the current knowledge base are highlighted and the authors outline possible directions for future investigations of treatment outcome. Improved methodology is suggested for the assessment of psychopathic disorder and the evaluation of treatment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The revised Psychopathy Checklist (PCL) is a 20-item scale scored from interview and file information. Analyses of data from 5 prison samples ( N = 925) and 3 forensic psychiatric samples ( N = 356) indicate that the revised PCL resembles its 22-item predecessor in all important respects. It has excellent psychometric properties, and it measures 2 correlated factors that were cross-validated both within and between samples. Correlations between the original PCL and the revised version approached unity for both the factors and the full scale. We conclude that the revised PCL measures the same construct as the original and that the PCL is a reliable and valid instrument for the assessment of psychopathy in male forensic populations. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The development of questionnaire scales to measure sensation seeking, first as a general trait and then as one with two or four facets, is described. Behavioral correlates of the trait include: volunteering for unusual or risky experiences, exceptional dangerous sports, fast and reckless driving, variety of sexual partners and activities, smoking, drinking and drugs, and risky or stressful vocations. Sensation seeking also influences preferences in art, media, music, movies, and television with a preference for novel, intense, and arousing themes like sex and violence.
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The author presents a report of the etiology and remission in a former forensic psychiatric patient who was found guilty for 13 crimes, including traffic offenses, fraud, thefts, rape, and assaults. He committed these crimes over a period of 11 years (from age 15 to 26). The patient was cured by therapeutic and psychosocial influences and by life events that made a strong impression on him. At present, he has been living for more than 20 years in freedom, leads a normal life, is happily married, and has never reoffended.
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The authors conducted a double-blind, placebo-controlled study of the effect of lithium on aggressive behavior. The 66 subjects, who were prisoners in a medium security institution, ranged in age from 16 to 24 years, were physically healthy and nonpsychotic, and had histories of chronic impulsive aggressive behavior. Subjects received lithium or placebo daily for up to 3 months. There was a significant reduction in aggressive behavior in the lithium group as measured by a decrease in infractions involving violence. The authors suggest that lithium can have a clinically useful effect upon impulsive aggressive behavior when this behavior is not associated with psychosis.
Article
Lithium was given to 27 recurrently violent convicts for 3–18 months. Characteristics of the population included inability to delay expression of aggressive feelings, strong suggestion of brain damage and a long history of violent behavior both in and out of prison.Assessments of change were composed of incidence and type of disciplinary actions and the number and type of security changes for identical time periods before and during lithium plus subjective reports by staff and subject.As a group, the average number of disciplinary actions for violent behavior decreased significantly whereas the average number of disciplinary actions for non-violent behavior did not decrease significantly. Individually considered, subjects received fewer disciplinary actions for violence. Security classifications improved. Subjective reports included: (1) An increased capacity to reflect on the consequences of actions; (2) increased capacity to control angry feelings when provoked; (3) diminished intensity of angry affect; and (4) generally a more reflective mood.
Article
Mortality data are presented from a 16- to 45-year follow-up study of 71 men with antisocial personality disorder. Death ascertainment was made through both a personal follow-up and use of the National Death Index. Comparisons were made with the mortality experience of the general population of the state of Iowa by using gender and age standardized mortality ratios. Seventeen men died (24%) died during the follow-up. Antisocial men younger than 40 years were at excessive risk for premature death (standardized mortality ratio [SMR] = 33, P < 0.25): men between ages 40 and 60 years also appeared to be at risk for premature death, although the excess was not statistically significant. Three subjects (18% of all deaths) died of complications from diabetes mellitus (SMR = 14, P < 0.05). Deaths were spread out among the four decades of follow-up. The findings and their implications are discussed.
Article
This paper reviews the autonomic psychophysiological correlates of antisocial and aggressive behavior in children and adolescents, outlines a biosocial perspective, and draws implications for treatment and prevention. Findings of studies on resting skin conductance and heart rate indicate that antisocial individuals are characterized by underarousal; these findings suggest that aggressive children may be stimulation seekers who are relatively fearless. Autonomic underarousal also typifies infants and young children with a disinhibited temperament that is thought to be a predisposition to juvenile delinquency and adult aggressive behavior. Deficits in the orienting response, a measure of attention allocation, also predisposes to later antisocial and criminal behavior. Initial studies have shown that particularly high levels of orienting, arousal, and conditionability may protect against crime development in those predisposed to such an outcome. From a biosocial standpoint, it is hypothesized that the psychophysiological correlates of antisocial and violent behavior may be greatest in those from more benign home backgrounds where the psychosocial push forward is relatively weaker. Alternatively, early environmental stress may underlie autonomic underarousal and hyporeactivity in antisocial individuals. Finally, it is possible that biofeedback, in combination with a multimodal treatment program, may be one benign intervention technique that may increase arousal and reduce aggression in underaroused antisocial children.
Article
The view that severe personality disorder (SPD) is untreatable derives from poor-quality studies of treatment outcome which use indirect measures of SPD pathology. This study evaluates the impact of psychotherapeutic in-patient treatment on core personality disorder symptoms. 137 SPD patients completed the Borderline Syndrome Index (BSI) on referral and one year post-treatment ('admitted', n = 70) or one year post-referral ('non-admitted', n = 67); 22 of the non-admitted group were refused extra-contractual referral funding for their treatment. There was a significantly greater reduction in BSI scores in the treated than in the non-admitted group. Changes in BSI scores were significantly positively correlated with length of treatment. Assessment of the reliability and clinical significance of changes in individual subjects showed that the magnitude of this change was reliable and clinically significant in 42.9% of the admitted sample, compared with only 17.9% of the non-admitted sample (18.2% of the unfunded group). Specialist in-patient treatment is effective in reducing core SPD psychopathology.